Neurology Book

Altered Level of Consciousness Causes

Aka: Altered Level of Consciousness Causes, Altered Mental Status Differential Diagnosis, ALOC Causes
  1. See Also
    1. Altered Mental Status in Febrile Returning Traveler
  2. Causes: Pitfalls - critical diagnoses that are easily missed
    1. Toxicologic Pitfalls
      1. Carbon Monoxide Poisoning
      2. Toxic Alcohol ingestion or Alcohol Withdrawal Syndrome
      3. Chronic Salicylate Toxicity
      4. Anticholinergic drug toxicity
      5. Neuroleptic Malignant Syndrome or Serotonin Syndrome
      6. Envenomation
      7. Opioid Overdose
      8. Benzodiazepine Overdose
    2. Endocrine Pitfalls
      1. Thyroid emergencies (Myxedema Coma, Thyroid Storm)
      2. Addisonian Crisis (Adrenal Insufficiency)
      3. Wernicke's Encephalopathy
    3. Infectious Pitfalls
      1. Cerebral Malaria
      2. Herpes Encephalitis
    4. Organ Failure Related Pitfalls
      1. Hypercarbia (CO2 Narcosis in COPD)
      2. Hepatic Encephalopathy
      3. Uremic encephalopathy
    5. Miscellaneous Pitfalls
      1. Non-convulsive Status Epilepticus
      2. Occult Trauma
      3. Thrombotic Thrombocytopenic Purpura
  3. Causes: Mnemonics
    1. Mnemonic: AEIOU TIPS
      1. Alcohol (or toxic Alcohols) or Abdominal Aortic Aneurysm
      2. Epilepsy (Status Epilepticus), Electrolytes, Hepatic Encephalopathy (or PRESS), endocrine problems
      3. Insulin (Hypoglycemia), Intussusception or Inborn Errors of Metabolism
      4. Opiates or Overdose
      5. Uremia
      6. Trauma (Closed Head Injury), Temperature (Hypothermia, hyperthermia), or Toxemia, Brain Tumor
      7. Infections (Sepsis, Meningitis, Encephalitis)
      8. Psychogenic, Pulmonary Embolism, Poisoning (Toxin Ingestion)
      9. Space occupying lesions, Stroke (including Intracranial Pressure), Shock, Seizure, shunt (ventriculoperitoneal)
    2. Mnemonic: I WATCH DEATH
      1. Infection
      2. Withdrawal
      3. Acute metabolic causes
      4. Trauma
      5. CNS Causes
      6. Hypoxia
      7. Deficiencies (Nutritional)
      8. Endocrinopathies (Adrenal Insufficiency, Myxedema, Hyperthyroidism)
      9. Acute Vascular Causes
      10. Toxins or Drugs
      11. Heavy Metals
    3. Mnemonic: SMASHED
      1. Sepsis or Substrates (abnormal Glucose, Thiamine deficiency)
      2. Meningitis or Mental Illness (acute Psychosis)
      3. Accident (Head Trauma, CVA) or Alcohol Intoxication or withdrawal
      4. Seizing or Stimulants
      5. Hypertension, Hyperthyroidism, Hypercarbia or Hypotension, Hypothyroidism, Hypoxia
      6. Electrolytes (Sodium, Hypercalcemia) or Encephalopathy
      7. Drugs (Drug Withdrawal, Carbon Monoxide, Lithium, steroids, Salicylates...)
  4. Causes: Neurologic - Supratentorial
    1. Unilateral hemispheric disease AND Brainstem Herniation
    2. Closed Head Injury (Concussion or Contusion)
    3. Meningitis or Encephalitis
    4. Hypertensive Encephalopathy
    5. Subarachnoid Hemorrhage or other Intracranial Hemorrhage (e.g. Epidural Hematoma, Subdural Hematoma)
    6. Ventriculoperitoneal Shunt Malfunction
    7. Cerebrovascular Accident
    8. Parkinsonism
    9. Myasthenia Gravis
    10. Seizure
      1. Post-ictal
      2. Non-convulsive Status Epilepticus
  5. Causes: Neurologic - Infratentorial
    1. Basilar ArteryOcclusion
    2. Brainstem tumor
    3. Cerebellar Hemorrhage
    4. Pontine Hemorrhage
    5. Traumatic posterior fossa Hemorrhage
  6. Causes: Toxins
    1. See Toxin Induced Altered Level of Consciousness Causes
    2. See Unknown Ingestion
    3. See Date Rape Drug
    4. Carbon Monoxide Poisoning
    5. Toxic Alcohol ingestion (e.g. Ethylene Glycol, Methanol)
    6. Alcohol Intoxication or Alcohol Withdrawal Syndrome
    7. Chronic Salicylate Toxicity
    8. Anticholinergic drug toxicity
    9. Neuroleptic Malignant Syndrome or Serotonin Syndrome
    10. Envenomation
    11. Excited Delirium (Cocaine, Methamphetamine, PCP, or other psychostimulant induced)
    12. Opioid Overdose
    13. Benzodiazepine Overdose
  7. Causes: Cardiopulmonary
    1. Hypoxia
    2. Hypercarbia
    3. Congestive Heart Failure (CHF)
    4. Pulmonary Embolus
  8. Causes: Gastrointestinal and Renal
    1. Hepatic Encephalopathy
    2. Wernicke's Encephalopathy
    3. Uremic encephalopathy
    4. Electrolyte disturbance
    5. Peritonitis
  9. Causes: Endocrine
    1. Adrenal Insufficiency (Addisonian Crisis)
    2. Diabetes Mellitus
      1. Hypoglycemia
      2. Diabetic Ketoacidosis
      3. Hyperosmolar Hyperglycemic Nonketotic Coma
    3. Thyroid disease
      1. Myxedema Coma
      2. Thyroid Storm
  10. Causes: Infectious
    1. Meningitis or Encephalitis
    2. Sepsis
  11. Causes: Miscellaneous
    1. Heat Stroke
    2. Hypothermia
    3. Vasculitis
    4. Hyperviscosity Syndromes (e.g. Thrombotic Thrombocytopenic Purpura)
  12. References
    1. Herbert et al. in Herbert (2014) EM:Rap 14(11): 10-12

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